The AAO Forum for Osteopathic Thought
JOURNALOfficial Publication of the American Academy of Osteopathy®
Tradition Shapes the Future Volume 23 Number 2 June 2013
Osteopathic medicine and spirituality...pg. 7 The American Academy of Osteopathy® is your voice ...... in teaching, advocating, and researching the science, art and philosophy of osteopathic medicine, emphasizing the integration of osteopathic principles, practices and manipulative treatment in patient care.
The AAO Membership Committee invites you to join the • Free subscription to the online AAO Member Newsletter. American Academy of Osteopathy as a 2013-2014 member. • Access to the members only section of the AAO website, The AAO is your professional organization. It fosters the which will be enhanced in the coming months to include new core principles that led you to choose to become a Doctor of features such as resource links, a job bank, and much more. Osteopathy. • Discounts on advertising in AAO publications, on the Web site and at the AAO’s Convocation. For just $5.01 a week (less than a large specialty coffee at your • The American Osteopathic Board of Neuromusculoskeletal favorite coffee shop) or just 71 cents a day (less than a bottle of Medicine, the only certifying board for manual medicine water), you can become a member of the professional specialty in the medical world today, accepts, without challenge, all organization dedicated to the core principles of your profession! courses sponsored by the AAO. Your membership dues provide you with: • Maintenance of an earned Fellowship program to recognize • A national advocate for osteopathic manipulative medicine excellence in the practice of osteopathic manipulative (including appropriate reimbursement for OMM services) medicine. with osteopathic and allopathic professionals, public policy • Promotion of research on the efficacy of osteopathic makers, the media and the public. medicine. • Referrals of patients through the Search for a Physician tool • Support for the future of the profession through the Student on the AAO website, as well as calls to the AAO office. American Academy of Osteopathy on osteopathic medical • Discounts on quality educational programs provided by AAO school campuses. at its annual convocation and weekend workshops. • Your professional dues are deductible as a business expense. • New online courses. If you have any questions regarding membership or • Networking opportunities with your peers. membership renewal, please contact Susan Lightle at (317) • Discounts on publications in the AAO Bookstore. 879-1881 or [email protected]. Thank you for • Free subscription to the AAO Journal published supporting the American Academy of Osteopathy. electronically four times annually.
NMM/Family Medicine and Osteopathic Residency Faculty Positions – Orlando, Florida
Florida Hospital Graduate Medical Education in Orlando, Florida, is looking for three dynamic, hardworking and broadly skilled family physicians with a passion for teaching for our osteopathic residency faculty. Family Medicine/Neuromusculoskeletal Medicine physician. Board Certi�ication in both FM and NMM (AOA) is required. This doctor would serve as one of the key faculty members within the Osteopathic Family Medicine Residency Program. He/ • she would focus on the Integrated NMM and Plus One NMM programs within the residency. Inpatient/hospitalist medicine with some outpatient care. Board Certi�ication in Family Medicine (AOA or ABMS) required. Outpatient care with some inpatient/hospitalist medicine. Board Certi�ication in Family Medicine (AOA or ABMS) required. • Responsibilities would include teaching for all of our residents and medical students. We teach six new residents each academic year,• along with two new residents each year in the FM/NMM program, and two fellows in the Plus One NMM program. The program also offers an Osteopathic Manipulation Fellowship, as well as the AOA-accredited Gynecologic Oncology program
Osteopathic Medicine. (one per year for the three-year program). Our main medical school af�iliation is with Nova Southeastern University College of This residency program is based at Florida Hospital East Orlando, a 225-bed facility that is part of one of the largest healthcare systems in the country. The Osteopathic Family Medicine Residency at East Orlando is among the most progressive training programs in the osteopathic profession. The foundation for our family medicine internship and residency is derived from the dedication of our faculty, continuity family medicine and pediatric clinics, didactic programs and innovative technology. NOTE: Not a Visa opportunity.
For more information, please contact Sarah Doherty, Physician Recruiter, at 407-200-2751, or e-mail CV to sarah.doherty@�lhosp.org.
Page 2 The AAO Journal Volume 23, Issue 2, June 2013 The AAO Forum for Osteopathic Thought OURNAL Official Publication of the American Academy of Osteopathy
JTRADITION SHAPES THE FUTURE • VOLUME 23 NUMBER 2 • JUNE 2013 The mission of the American Academy of Osteopathy® is to teach, 3500 DePauw Boulevard advocate and research the science, art and philosophy of osteopathic Suite 1080 medicine, emphasizing the integration of osteopathic principles, Indianapolis, IN 46268 practices and manipulative treatment in patient care. Phone: (317) 879-1881 Fax: (317) 879-0563 In this Issue: www.academyofosteopathy.org AAO Calendar of Events...... 5
American Academy of Osteopathy® CME Certification of Home Study Forms...... 14 David Coffey, DO, FAAO...... President Component Society Calendar of Events...... 32 Kenneth J. Lossing, DO...... President-Elect Editorials: Diana L. Finley, CMP...... Executive Director Reflections on our recent past and thoughts about our future...... 4 Murray R. Berkowitz, DO, MA, MS, MPH Editorial Advisory Board Denise K. Burns, DO, FAAO View from the Pyramids: Osteopathic medicine and spirituality...... 7 Kate McCaffrey, DO Eric J. Dolgin, DO Claire M. Galin, DO Distance learning and osteopathic manipulative medicine...... 9 Janice U. Blumer, DO William J. Garrity, DO Stephen I. Goldman, DO, FAAO Original Contribution: Stefan L. J. Hagopian, DO, FAAO Treatment of a posterior rib utilizing a multimodal sequence of Raymond J. Hruby, DO, MS, FAAO osteopathic manipulative treatments...... 10 Joshua P. Baker, DO, FAAFP; Rachel Ely, MHA, OMS III Brian E. Kaufman, DO Hollis H. King, DO, PhD, FAAO Case Study: David C. Mason, DO Relief of persistent jaw pain with the use of osteopathic manipulative Kate McCaffrey, DO medicine...... 15 James A. Lipton, DO, FAAO, FAAPMR; J. Daren Covington, OMS IV Paul R. Rennie, DO, FAAO Hallie J. Robbins, DO International Contributions: Mark E. Rosen, DO In the hands of an angel...... 19 Jamie B. Archer, DO (UK) The AAO Journal The liquorodynamic model of the primary respiratory mechanism...... 24 Kate McCaffrey, DO...... Interim Scientific Editor Yuri E. Moskalenko, DSc., DO (Hon.); Tamara I. Kravchenko, PhD, DO; Diana Finley, CMP...... Supervising Editor Gustav B. Weinstein, PhD; Terence C. Vardy, DO Tessa Boeing...... Managing Editor Advertising Rates The AAO Journal is the official publication of the American Academy Placed 1 time Placed 2 times Placed 4 times of Osteopathy.® Issues are published in March, June, September, and December each year. Full Page 7.5” x 10” $600 $575 $550 Half Page 7.5” x 5” $400 $375 $350 The AAO Journal is not responsible for statements made by any Third Page 7.5” x 3.3” $300 $275 $200 contributor. Although all advertising is expected to conform to ethical medical standards, acceptance does not imply endorsement by Fourth Page 3.75” x 5” $200 $175 $150 this journal. Professional Card 3.5” x 2” $60 Opinions expressed in The AAO Journal are those of the authors and Classified $1.00 per word do not necessarily reflect viewpoints of the editors or official policy of the American Academy of Osteopathy® or the institutions with Advertising rates for The AAO Journal, official publication of the ® which the authors are affiliated, unless specified. American Academy of Osteopathy (AAO). AAO and American Osteopathic Association affiliate organizations and members of the Please send e-mail address changes to: Academy are entitled to a 20 percent discount on advertising in this [email protected] journal. Call the AAO at (317) 879-1881 for more information.
Volume 23, Issue 2, June 2013 The AAO Journal Page 3 Reflections on our recent past and thoughts about our future
Murray R. Berkowitz, DO, MA, MS, MPH
I submitted my letter of resignation as Scientific to stimulate intellectual dialogue, and the publication of Editor for this journal and the Board of Trustees of our ideas and proposed studies, on some of the controversial Academy has accepted it. Thus, this is my last formal and unknown areas of OMM. I hoped that more of my editorial as Scientific Editor. I realized that I needed to colleagues would reflect on what was published and step away from the duties and responsibilities of Scientific contribute their thoughts by submitting Letters to the Editor to concentrate on other equally important and Editor, commentaries or review articles, as well as original challenging things in my life. research papers. Among these is returning to work toward achieving I thank those who did submit manuscripts for the degree of Fellow of the American Academy of consideration and hope submissions continue to increase. Osteopathy (FAAO), as well as continuing to develop my I leave my successor with my goal of getting our journal research goals, especially regarding clinical applications of listed in PubMed. I feel once we are included there, Osteopathic Manipulative Medicine (OMM)/Osteopathic and in other citation indexes, more of our scientific and Manipulative Treatment to Traumatic Brain Injury (TBI) research colleagues will consider the American Academy of and Post-Traumatic Stress Disorder (PTSD) in our military Osteopathy Journal (AAOJ) as a forum for their work. service members and veterans. I would also like to increase Thinking about our future, I encourage this journal to my work with the Joining Forces Initiative Working Group, continue to publish a special, themed issue once each year. and further add to our base of evidence in the osteopathic I am most proud of the special military-themed issue the medicine milieu. AAOJ published intentionally on July 4, 2012. This journal As I depart, I have looked back at some of the things had an opportunity to use momentum from the White I accomplished for our journal, and also looked toward House Joining Forces Initiative and be the first within goals I leave for my successor. Reflecting on our recent the osteopathic community to publish in the areas of TBI past, I increased the scientific and professional content and PTSD. For a number of reasons, this did not happen of our journal. You have undoubtedly noticed changes in and our esteemed colleagues at the American College of the table of contents, and I hope you approve. I published Osteopathic Family Physicians (ACOFP) published their more FAAO theses and increased the contributions of our special, military-themed issue of Osteopathic Family osteopathic medical students, interns and residents, and Physician in March 2012. My hat is off to Jay H. Shubrook, international colleagues. Jr., DO, FACOFP (Editor) and Merideth Norris, DO, FACOFP (Associate Editor) on a very fine job and for I also discussed ways for the osteopathic profession being able to produce a quality issue so quickly. to increase formal training opportunities leading to board certification in Neuromusculoskeletal Medicine (NMM)/ However, their accomplishment does not diminish the OMM, open osteopathic graduate medical education quality of what this journal published or our achievements to allopathic physicians, and increase evidence-based in contributing to this important area. These two issues of osteopathic medicine research. A little over a year ago, our respective osteopathic medical journals provide the I began working with the editors of the Journal of the entire medical community with important information, American Osteopathic Association (JAOA) to provide and serve as much needed, peer-reviewed resources for closer ties between our journals and increase publishing rendering care to our military service members, veterans opportunities for peer-reviewed research papers in NMM/ and their families. It was indeed a labor of love. OMM. I encourage this journal to continue to work closely I am very proud of the 75th Anniversary issue of the with the JAOA. journal last year. This special issue included what I felt I also tried stimulating thought through my editorials to be seminal papers in the osteopathic profession. As and by publishing Letters to the Editor (and author previously stated in my editorials, I followed and stood on responses). I feel I was successful to some degree. I wanted the shoulders of Anthony G. Chila, DO, FAAO; Robert C. continued on page 7
Page 4 The AAO Journal Volume 23, Issue 2, June 2013 AAO Calendar of Events
Mark your calendar for these upcoming Academy meetings and educational courses.
2013 July 12-13 AAO Board of Trustees Meeting— Embassy Suites North, Indianapolis, IN July 15-18 AOA Board of Trustees Meetings—The Fairmont Hotel, Chicago, IL July 18-22 AOA House of Delegates Meetings—The Fairmont Hotel, Chicago, IL August 9-10 Education Committee Meeting— The Westin Hotel, Indianapolis, IN August 9-10 SAAO Council Meeting—The Westin Hotel, Indianapolis, IN August 28 Fellowship Committee Web Conference, 8:30 pm EDT September 29 AAO Board of Trustees Meeting—Mandalay Bay Resort, Las Vegas, NV September 29 Case-Based Osteopathic Sports Medicine (Pre-OMED)—Kurt P. Heinking, DO, FAAO Mandalay Bay Resort, Las Vegas, NV Sep. 30-Oct. 2 Osteopathic Approach to Common Office Complaints (AAO Program at OMED) Laura E. Griffin, DO, FAAO—Mandalay Bay Resort, Las Vegas, NV October 10-12 Prolotherapy Weekend—George J. Pasquarello, DO, FAAO; Mark S. Cantieri, DO, FAAO UNECOM, Biddeford, ME November 8 AOBNMM Meeting—Crowne Plaza Hotel, Indianapolis, IN November 9 AOBNMM Oral & Practical Exams—Crowne Plaza Hotel, Indianapolis, IN November 10 AOBNMM Written Exam—Crowne Plaza Hotel, Indianapolis, IN December 6-8 Heart and Vascular Course—Kenneth J. Lossing, DO—AZCOM, Glendale, AZ
2014 March 15-18 New Approach to Osteo-Articular Manipulations Including the Superior and Inferior Limbs (Pre-Convo) Jean-Pierre Barral, DO (France); Kenneth J. Lossing, DO—The Broadmoor Hotel, Colorado Springs, CO March 17-18 Pediatrics Course (Pre-Convo)—Heather P. Ferrill, DO—The Broadmoor Hotel, Colorado Springs, CO March 17-18 Myofascial Trigger Points Course (Pre-Convo)—Michael L. Kuchera, DO, FAAO The Broadmoor Hotel, Colorado Springs, CO March 19-23 AAO Convocation—Trauma: An Integrated Osteopathic Approach—Denise K. Burns, DO, FAAO The Broadmoor Hotel, Colorado Springs, CO
Volume 23, Issue 2, June 2013 The AAO Journal Page 5 Osteopathy and Swedenborg by David B. Fuller, DO, FAAO Now available in the AAO bookstore!
Osteopathy & Swedenborg demonstrates the previously unrecognized influence of Swedenborg’s ideas on the creation and development of osteopathic medicine, especially in regards to body/mind/spirit and the anatomical inter-relationship of the nervous system, fascia and fluids throughout the body. This includes a study of cranial osteopathy and Swedenborg’s paradigm of the brain and soul-body interaction, comparing concepts such as Swedenborg’s spirituous fluid and Sutherland’s Primary Respiratory Mechanism. In the process of making these connections, the book traces the influence of Swedenborg’s ideas through and across the America of the 1800s, specifically through the metaphysical/ healing movements of Transcendentalism, Spiritualism, New 624Thought pp. Hardbackand Theosophy. ISBN: 978-0-910557-82-5
David Fuller’s text, is a thorough analysis of the influence the writings of eighteenth-century Swedish scientist and theologian, Emanuel Swedenborg, had on Andrew Taylor Still, William Garner SutherlandOsteopathy and and other Swedenborg, seminal osteopathic thinkers. It behooves any serious osteopathic practitioner, scholar or educator to read this thought-provoking work. —Kenneth E. Nelson
, DO, FAAO, FACOFP (Dist.), Professor, Department of Osteopathic Manipulative Medicine, Chicago College of Osteopathic Medicine, and Editor of Somatic Dysfunction in Osteopathic Family Medicine
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Kate McCaffrey, DO
“Dear God, please save my brother.” None of us has all the answers to life and death and everything in between. I do not know why a beautiful “Doctor, is there anything else you can do for my 18-year-old female was carried into my emergency room by mother?” her mother after being shot through the chest. I know only How many times have we encountered clinical some of the reasons why fetuses spontaneously abort. I do scenarios like these while taking care of our patients? As not know why people get cancer other than the reason we osteopathic physicians, we deal with end-of-life issues, were taught in medical school. serious illnesses and devastating injuries on a daily basis; Medicine can explain a lot scientifically, but it some of us more frequently than others. How can we cannot account for everything. There are questions that comfort our patients and their families in times of medical my medical training did not prepare me to deal with when need when traditional Western medicine is already on board? taking care of patients. I know I have a compassionate Spirituality is one answer. Spirituality has been framework in which to place these events and from which defined as “a person’s experience of, or a belief in, a power to counsel my patients. This is the osteopathic philosophy, apart from his or her own existence.”1 Spirituality is about and for this tool I am forever grateful. the relationship between us and something larger. It means References being in the right relationship with all that is. Spirituality comes into focus in times of emotional stress, physical 1 Mohr WK. Spiritual issues in psychiatric care. Perspect Psychiatr Care. 2006;42(3):174-183. illness, loss, grief and death.2 2 Murray RB, Zentner JP. Nursing Concepts for Health Promotion. What does the history of osteopathic medicine say London: Prentice Hall; 1989. about spirituality? Dr. Andrew Taylor Still taught us about 3 Chila AG, ed. Foundations of Osteopathic Medicine. 3rd ed. providing emotional support and encouragement to our Philadelphia, PA: Lippincott Williams & Wilkins; 2011:13-14. patients dealing with end-of-life conditions.3 Our Five Model approach to the philosophy of medicine teaches continued from page 4 us about spirituality in its Behavioral Model; we are taught to “assess and treat the whole person – physical, Clark, DO, MS; and, most recently, Raymond J. Hruby, psychological, social, cultural, behavioral and spiritual.”3 DO, MS, FAAO, as editors of this journal. In preparing the th So what are we to do with this information as trusted 75 Anniversary issue, I noted that I also built on the work physicians and physicians-in-training? One of the strengths of such luminaries as Thomas L. Northup, DO; George W. of osteopathic medicine is the philosophy of evaluating the Northup, DO, FAAO; Perrin T. Wilson, DO: and so many whole person and treating the body as a unit. Many of my others. As stated then, “By this knowledge, I am even patients have commented that I listen well. We are taught further humbled.” I can only hope these leaders would to listen to our patients with this philosophy in mind. I am approve of my work in advancing the art and science of a trained listener and I do this in the context of the four osteopathic medicine. general osteopathic principles we know well. Kate McCaffrey, DO, joined the AAOJ as Associate As a physician, I am a highly trained technician and Editor last fall. Her editorials have been intelligent, mechanic. I have also been trained to set aside my own articulate and thought-provoking. The Board of Trustees beliefs (except to inform patients of rational and modern has appointed her Interim Scientific Editor. I hope you will medical options) and to support them in their spiritual and join me in wishing her the very best in her new role and cultural paradigm. When I listen in this way, I give patients that you will also join me in helping her as she leads our the dignity, support and respect they deserve. Academy’s efforts to make the AAOJ even better.
Volume 23, Issue 2, June 2013 The AAO Journal Page 7 Case-Based Osteopathic Sports Medicine
September 29, 2013, in Las Vegas, NV (Pre-OMED)
Course Description Program Chair This one-day, pre-American Osteopathic Kurt P. Heinking course will be an interactive discussion , DO, FAAO, is a 1994 graduate andAssociation demonstration Convention of manipulative (OMED) of Chicago College of Osteopathic Medicine, techniques for common sports injuries where he currently serves as Chair of the of the extremities. Time will be ManipulativeDepartment of Medicine, Osteopathic Family Manipulative Medicine divided between case presentation, Medicine. He is board certi�ied in Osteopathic demonstration of orthopedic testing, musculoskeletal medicine practice in Willowbrook, IL. palpatory assessment, and manipulative and Sports Medicine, and has a private CME treatment for extremity injuries. Both indirect and direct osteopathic manipulative treatment (OMT) 8 hours of AOA Course Times goals, return to play and injections are welcome. Category 1-A credit are anticipated. modalities will be demonstrated. Discussion on rehabilitation Sunday: 8:00 am - 5:30 pm Course Objectives The participant will be able to: theirIncludes own (2) meals. 15-minute breaks and a (1) hour-long lunch. extremity issues. Coffee will be provided, but participants are responsible for • Learn how to �ind and treat the axial component in Course Location and rotator cuff pathology. Mandalay Bay Hotel • LearnDiagnose lymphatic and treat techniques shoulder forimpingement the upper and syndromes lower extremities. • 3950 S. Las Vegas Blvd. LasTravel Vegas, Arrangements NV 89119 Call Tina Callahan • ApplyDiagnose manipulative and treat trochanter techniques bursitis, to the wrist iliotibial and foot.band friction syndrome and �ibula somatic dysfunction. of Globally Yours Travel at 1-800-274-5975. •
Registration Form Registration Rate: $225 Case-Based Osteopathic Sports Medicine September 29, 2013 in Las Vegas, NV The AAO accepts check, Visa, Mastercard or Discover payments Name: ______in U.S. dollars Nickname for Badge: ______AOA#: ______Credit Card #: ______Cardholder’s Name: ______ExpirationAddress associated Date: ______with card: ______3-digit CVV#______Street______Address: ______
Phone: ______Fax: ______I hereby authorize the American Academy of Osteopathy to City: ______State: ______Zip: ______charge the above credit card for the full course registration E-mail: ______amount. By releasing your fax/e-mail, you have given the AAO permission to send marketing information regarding courses to your fax or e-mail. Signature: ______AAO’s Cancellation and Refund Policy Click here to view the Please submit registration form and payment via mail to the American Academy of Osteopathy, 3500 DePauw Blvd., Suite 1080, Indianapolis, IN 46268 or by fax to (317) 879-0563. Or register online at www.academyofosteopathy.org
Page 8 The AAO Journal Volume 23, Issue 2, June 2013 Distance learning and osteopathic manipulative medicine
Janice U. Blumer, DO
“I expect that when I am gone… I will come back every week or so to see what Osteopathy is doing.”1 Andrew Taylor Still
“What would A.T. Still think?” replays in my mind trainers who had previously taught traditional cranial as I see images of a high velocity low amplitude technique courses, the consensus was reached that it was no different being taught 900 miles south of me displayed on a giant than having the presenter on stage. screen. I am faculty at a distant campus, which is now As our profession has grown exponentially in the last becoming the norm in osteopathic medical education. With 10 years, it is becoming increasingly more difficult to meet the explosion in growth of osteopathic medicine and the the needs of the more labor-intensive psychomotor courses. addition of many new sites, one of the greatest challenges is Technology, when used wisely, can help meet these needs. keeping up with hands-on training while also using distance Though it does not replace the one-on-one instruction that learning modalities. allows for the refinement of techniques, it can help maximize Systems such as HaiVision and Lync allow real-time the resources needed for psychomotor training. I can only interaction with a professor at a distant site. With this think that A.T. Still would be smiling at these innovations to high-tech version of the traditional classroom, one might support osteopathic medicine’s hands-on traditions. ask, “What does it take to learn Osteopathic Manipulative Medicine (OMM)? How much direct contact is needed? References And, in this age of You Tube, are professors of OMM 1 Still AT. The Autobiography of A.T. Still. Kirksville, MO: becoming obsolete? Published by the author; 1908: 276. My assessment is that these tools provide an adjunct to traditional hands-on training, but will by no means replace the one-on-one instruction it takes to learn a Sutherland Cranial Teaching Foundation psychomotor skill. They allow for the basis of a concept or Upcoming Courses technique to be presented, while the “meat and potatoes” is still the direct instruction received from either a teaching assistant, fellow or faculty member. It also allows for the dissemination of knowledge and utilization of faculty from SCTF Intermediate Course: a primary site, therefore keeping the need for faculty at a Beyond the Basics: Additional Sutherland Procedures distant site to a minimum. October 11th (beginning at noon), 12th and 13th, 2013 Midwestern University • Glendale, Arizona There are challenges to this high-tech learning, Register Prior to August 31, 2013: $750 especially for the distant site. It is difficult to assess the Register After September 1, 2013: $825 pace of the class or lab when one is not physically present. Prerequisites: Successful completion of two (2) Basic It is also very easy to lose the attention of those at the Courses. One (1) must have been an SCTF Basic Course. distant site when someone is only present onscreen. We Course Director: Edna Lay, DO, FAAO have overcome many of these issues by having a camera 20 Hrs 1A CME anticipated view of both campuses, and using interactive tools such Hotel: Sheraton Crescent Hotel Phoenix as clickers. Engaging the distant site is crucial to keeping 2620 W. Dunlap Avenue focus. Phoenix, AZ 85021 It is also important to know when to utilize this tool. We have found we can often connect for a portion of the Visit our website for enrollment hour, then leave the remainder of the hour for hands-on, forms and course details: www.sctf.com Contact: Joy Cunningham 509-758-8090 site-specific practice. In this way, each campus can move Email: [email protected] independently and utilize on-site resources. We were also successful in the first ever, distance-site linked, 40-hour osteopathic cranial course. In discussion with the table
Volume 23, Issue 2, June 2013 The AAO Journal Page 9 Treatment of a posterior rib utilizing a multimodal sequence of osteopathic manipulative treatments
Joshua P. Baker, DO, FAAFP; Rachel Ely, MHA, OMS III
Introduction Using Strain-Counterstrain to address a posterior rib, Individual techniques (i.e., High Velocity Low the patient should be placed in a seated position with the Amplitude, Muscle Energy, Facilitated Positional Release, physician standing behind. Once a posterior rib lesion is Myofascial Release, etc.) typically focus on a single identified, the tender point is localized to begin the process component of somatic dysfunction, such as the fascia, bone, with a modified Strain-Counterstrain technique. The tendon, ligament or muscle, depending on the technique physician supports the arm ipsilateral to the dysfunction used. However, dysfunctions are typically a complicated in approximately 90 degrees of abduction. The thorax and mixture of dysfunctional tissues. Utilization of a single technique will treat one component of a dysfunction, but can leave remaining dysfunctional tissues behind. For Osteopathic Manipulative Treatment (OMT) to be maximally efficacious, a variety of techniques may be needed to address even a single dysfunction. The authors propose that, over time, many practitioners have developed what we refer to as “multimodal sequences” of OMT for the treatment of specific somatic dysfunctions. These are defined as the simultaneous and/or sequential application of a variety of different techniques, each in immediate succession and Figure 1 all to treat a single dysfunction. There is no published literature on the concept of multimodal sequences of OMT, even though this application is likely common in the practices of those who utilize OMT. The authors also propose a multimodal sequence of OMT, which consists of a series of five established techniques, for the treatment of a posterior rib dysfunction. Methods For review purposes, these individual techniques and their target tissues are defined in the order of application within this multimodal sequence. Figure 2 Strain-Counterstrain: As defined by its developer, Lawrence H. Jones, DO, Strain-Counterstrain is the “relieving [of] spinal or other joint pain by passively putting the joint into its position of greatest comfort.”1 More specifically, Jones defines it as the relief of pain by “reduction and arrest of the continuing inappropriate proprioceptor activity…by markedly shortening the muscle that contains the malfunctioning muscle spindle by applying mild strain to its antagonists.”1 These positions of comfort are traditionally maintained for 90 seconds1 and address mainly myofascial and muscular dysfunctions. Figure 3
Page 10 The AAO Journal Volume 23, Issue 2, June 2013 neck are flexed and sidebent away from the dysfunction.2 “Push Me, Pull You” technique as described by Mitchell.8 See Figures 1 and 2. This position may be held for the The physician places a hand on the elbow and resists the traditional 90 seconds, although therapeutic tissue texture patient’s attempt at abduction, while the arm is still across changes may occur at a shorter time interval, at which point the chest, keeping the patient’s elbow at the level of the the multimodal sequence should continue. dysfunction. See Figure 6. This motion recruits the middle trapezius and the rhomboids to treat the rib dysfunction Facilitated Positional Release (FPR): FPR indirectly. principally treats muscle tissue dysfunction by placing a dysfunctional tissue passively into a neutral position with These aforementioned muscles provide a force at the addition of a facilitating force applied through the the spinous processes, causing a rotation of the vertebrae region. This effectively shortens the muscle and lowers contralaterally, which results in the ipsilateral transverse excitatory output.3 processes moving anteriorly. This simultaneously moves the attaching rib anteriorly by its action at the To address the posterior rib in the multimodal costotransverse joint, which simultaneously releases a sequence, the physician repositions the arm from the Strain- restriction at the costovertebral joints. The final sequence Counterstrain position into increased shoulder abduction utilizes an articulatory technique. with elbow flexion, and a compressive force through the shoulder is directed toward the dysfunction.4 See Figure Articulatory Technique: This is a direct technique 3. Once tissue release has been confirmed, the multimodal that forces a dysfunctional area through a barrier by sequence should continue. applying a gentle force. This technique is especially useful for mobilizing joints.7 Still Technique: The Still Technique essentially follows a three-step pattern: lesion isolation and The final step in the multimodal sequence is an exaggeration, a compressive force and a low-velocity articular circumduction starting with the arm across the articulation directly through the restriction.5 This technique chest in approximately 90 degrees of flexion (depending on principally addresses bony restrictions.4 the level of the dysfunction), with full adduction traversing superiorly, then ending in full shoulder extension, In the case of the posterior rib, FPR is converted adduction and internal rotation to ensure adequate motion smoothly into Still Technique by maintaining compression, at the scapulothoracic joint. See Figures 7, 8 and 9. This and exaggerating the dysfunction with increased abduction active mobilization of the scapulothoracic joint provides combined with extension at the shoulder. See Figures 4 direct force on any posterior rib to gently mobilize it and 5. The glenohumeral and scapulothoracic joint are then anteriorly. articulated, with the arm passively moved into adduction and flexion and coming to rest across the patient’s chest, The reader may refer to the following video which where the treatment transitions to Muscle Energy.4,6 displays the aforementioned treatment in greater detail: http://youtu.be/vf02yzlnxLA . Muscle energy: This technique requires the patient’s cooperation to recruit specific muscle groups on request Discussion against a counterforce applied by the physician. Muscle The authors have observed significant resolution of Energy addresses musculature and can also mobilize dysfunction using this multimodal sequence of OMT to 7 joints. treat a posterior rib dysfunction. There is no published Muscle Energy is easily performed from the final literature regarding multimodal sequences of OMT, but Still Technique position, which is a modification of the it stands to reason that the combination of established
Figure 4 Figure 5 Figure 6
Volume 23, Issue 2, June 2013 The AAO Journal Page 11 Figure 7 Figure 8 Figure 9 techniques (even with minor modifications) is likely technique may be attempted after the first has left the more efficacious since they address a wider variety of dysfunction unresolved. dysfunctional tissues comprising the totality of the somatic The authors propose that, in reality, those who employ dysfunction. This method can also be more time efficient, OMT commonly treat lesions with multimodal sequences as the dysfunction does not have to be readdressed if the that transition seamlessly from one to another, often with no initial technique proves not to fully resolve the dysfunction. pause or reevaluation of the dysfunction in the interim. This It can additionally be performed without repositioning or presents a potential disparity between OMT in academia and reevaluating between techniques. in practice. A transition from technique-based training to The education of osteopathic medical students region- or dysfunction-based training once the fundamentals currently utilizes a technique-based approach to OMT are mastered may aid students in developing the multimodal that is rigidly divided into categories primarily based sequences osteopathic physicians are likely to employ, and on technique. This is mirrored in the layout of OMT also allow patients to receive greater treatment benefit. techniques in the Foundations of Osteopathic Medicine While examples of a sequential model undoubtedly textbook. The application of multimodal sequences of OMT exist in abundance, they currently benefit only the utilizes a dysfunction-based approach, which is nearly developer him/herself and perhaps a few fortunate students. the antithesis of a technique-based approach. The purely The authors urge those utilizing multimodal sequences of dysfunction-based approach to OMT presents an interesting OMT to submit them for publication for the edification dilemma on how OMT is taught to osteopathic students, of the entire osteopathic community. The authors have residents and physicians. In addition, students are taught submitted this first multimodal sequence as an initial model to adopt a stepwise approach to treatment; a subsequent for future publications. Conclusion The authors propose there be no change in the CME QUIZ education of novice osteopathic medical students and The purpose of the quiz, found on page 14, is to provide suggest the continuation of a technique-based approached a convenient means of self-assessment for your reading to OMT. However, there should be a transition to a of the scientific content in “Treatment of a posterior dysfunction- or body-region based approach to OMT in rib utilizing a multimodal sequence of osteopathic residents, and it is recommended that continuing medical manipulative treatments” by Joshua P. Baker, DO, FAAFP education activities also utilize multimodal sequences and Rachel Ely, MHA, OMS III. of OMT. The authors call for further publication of Please answer each question listed. The correct answers multimodal sequences of OMT by those who already utilize will be published in the September 2013 issue of the AAOJ. them in the treatment of their patients. To apply for Category 2-B CME credit, record your Acknowledgements answers to the AAOJ CME quiz application form answer The authors would like to acknowledge Tony Nguyen, sheet on page 14. The AAO will note that you submitted MLIS for his expertise in literature search. the form, and forward your results to the AOA Division of CME for documentation. You must score a 70 percent or References higher on the quiz in order to receive CME credit. 1 Jones LH. Strain-Counterstrain. Colorado Springs, CO: American Academy of Osteopathy; 1981: 11, 13.
Page 12 The AAO Journal Volume 23, Issue 2, June 2013 2 Rennie PR. Counterstrain & Exercise: An Integrated Approach. 7 Chila AG, ed. Foundations for Osteopathic Medicine. 3rd ed. 2nd ed. Williamston, MI: RennieMatrix; 2004: 61. Baltimore, MD: Lippincott Williams & Wilkins; 2011: 834, 881. 3 Schiowitz S. Facilitated positional release. JAOA. 1990; 2:145- 8 Mitchell FL, Mitchell PKG. The Muscle Energy Manual. East 146. Lansing, MI: MET Press; 1998: 144. 4 DiGiovanna EL, Schiowitz, S, Dowling DJ. An Osteopathic Approach to Diagnosis and Treatment. 3rd ed. Philadelphia: Accepted for publication: May 2013 Lipincott Williams & Wilkins; 2005: 94, 384-385. Address correspondence to: 5 Van Buskirk RL. A manipulative technique of Andrew Taylor Still Joshua P. Baker, DO, FAAFP as reported by Charles Hazzard, DO, in 1905. JAOA. 1996;10:601. West Fork Family Medicine, PC 6 Van Buskirk RL. The Still Technique Manual: Applications of 705 Elm Street East a Rediscovered Technique of Andrew Taylor Still. Indianapolis: Rockwell, Iowa 50469 American Academy of Osteopathy; 2000: 46. [email protected]
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NEW NMM PLUS 1 RESIDENCY PROGRAM IN NEW YORK There is a new NMM Plus 1 Residency at Southampton Hospital in beautiful Southampton, Long Island. Applications are currently being accepted. If interested, please contact Program Director Denise K. Burns, DO, FAAO, at [email protected] or Education Department Secretary Karen Roberts at (631) 726-0409. PRACTICE OSTEOPATHY IN BEAUTIFUL COLORADO Successful integrative practice seeks a board-certified/eligible NMM/OMM physician for its busy Denver office. Preferably someone comfortable with a broad variety of techniques. Very competitive compensation. Friendly and professional atmosphere. Please call (303) 781-7862 or e-mail CV to [email protected]. Our Web site is www.cointegrative.com. SEEKING DO IN LOS ANGELES Innovative primary care practice seeks primary care physician also interested in OMM. Balanced lifestyle, work with academically trained MDs, started by original designer of Epocrates. Additional opportunities available in the San Francisco Bay Area, NYC, Boston and Washington, DC. If interested, please send a brief intro and CV to [email protected]. PHYSIATRY OPENING IN SOUTH FLORIDA Position available for AOA Board Certified PM&R with OMT skills and/or NMM background. South Florida. No nights, call or weekends. Competitive salary, good benefits, Osteopathic Medical School and GME participation. Spanish speaking is also a plus. Please email CV to [email protected]. FAMILY PRACTICE IN COLORADO LOOKING FOR PHYSICIAN Looking for DO for established family practice with lots of OMT. Part time June-July needed urgently. Evergreen, CO. Currently solo with two PAs, excellent staff. Beautiful mountain town, great schools. Contact Richard Staller, DO, at (720) 352-9909 or [email protected]. NMM PLUS 1 POSITIONS AVAILABLE IN SUNNY SOUTH FLORIDA Residency program at Larkin Hospital. Contact Joel D. Stein, DO, FAAO, at (954) 563-2707 or [email protected] for more information. PRACTICE FOR SALE IN CONNECTICUT Practice available in Hartford, CT. Primarily specializes in OMT, prolotherapy and chronic pain management. Income for 2012 was 700K, with net income of 335K. Much more to explain regarding demographics of the community, hospitals in the area and beautiful nearby reisdential areas. If interested, please contact Gary N. Wiessen at (631) 281-2810 or [email protected].
Volume 23, Issue 2, June 2013 The AAO Journal Page 13 American Osteopathic Association Continuing Medical Education
This CME Certification of Home Study Form is intended to document individual review of articles in theAmerican Academy of Osteopathy Journal under the criteria described for Category 2-B CME credit.
CME CERTIFICATION OF HOME STUDY FORM This is to certify that I, ______Mail this page to: Please print name American Academy of Osteopathy 3500 DePauw Blvd. READ the following article for AOA CME credits. Suite 1080 Indianapolis, IN 46268 Name of Article: Treatment of a posterior rib utilizing a multimodal sequence of osteopathic manipulative treatments Authors: Joshua P. Baker, DO, FAAFP; Rachel Ely, MHA, 1. The main idea of the article, Treatment of a posterior OMS III rib utilizing a multimodal sequence of osteopathic manipulative treatments, focuses on a single somatic Publication: AAO J, Volume 23, No. 2, June 2013, pp. 10-13 dysfunction. a. True Category 2-B credit may be granted for these articles. b. False 00______AOA Number 2. In Baker’s article, the following description most closely describes which technique?: “relieving [of] spinal or other Full name: ______joint pain by passively putting the joint into its position of (Please print) greatest comfort” Street address: ______a. A.T. Still b. Articulatory City, state, zip: ______c. Facilitated Positional Release d. Muscle Energy Signature: ______e. Strain-Counterstrain
FOR OFFICE USE ONLY 3. The following description most closely describes which Category: 2-B Credits:______Date: ______technique outlined in the article?: “lesion isolation and exaggeration, a compressive force and a low-velocity Complete the quiz to the right by circling the correct articulation directly through the restriction” answer. Mail your completed answer sheet to the AAO. The a. A.T. Still AAO will forward your results to the AOA. You must have b. Articulatory 70 percent accuracy in order to receive CME credits. c. Facilitated Positional Release d. Muscle Energy e. Strain-Counterstrain March 2013 AAO Journal CME quiz answers: 1. B 4. The authors propose that utilization of a multimodal 2. C sequence of OMT be taught to residents and not novice 3. B medical students. 4. D a. True b. False Answers to the June 2013 AAOJ CME quiz will appear in the September 2013 issue.
Page 14 The AAO Journal Volume 23, Issue 2, June 2013 Relief of persistent jaw pain with the use of osteopathic manipulative medicine
James A. Lipton, DO, FAAO, FAAPMR; J. Daren Covington, OMS IV
The views in this article are those of the authors and do not re- known as reactive tumors and are a result of interrupted flect the official policy or position of the Department of the Navy, axons. After injury, the nerve begins to regenerate. the Department of Defense or the United States Government. However, due to the destruction of the endoneurial tube, Abstract a disorganized group of axons begin growing in multiple directions. This can result in a painful and tender nerve Residual jaw pain is a complication that can occur mass.3 following removal of a lower third molar. This is the case report of a patient who reported right jaw pain after right A 1990 study reviewing the frequency of traumatic lower third molar surgery. The patient underwent extensive neuromas determined that 45 out of the 48,944 dental testing and multiple examinations that did not determine procedures, or 0.09 percent of cases, led to the formation the cause of the unexpectedly persistent pain. Multiple of a neuroma. Out of these 45 cases, 30 were asymptomatic attempts at treatment without the use of Osteopathic and 15 were painful. Of the 15 painful neuromas, only three Manipulative Medicine (OMM) by other providers failed were identified as traumatic neuromas. The data did show to remove the patient’s pain. The patient was evaluated a two-to-one ratio of female to male predominance, but the and treated, and reported her jaw pain had been eliminated relationship could only be speculated.4 through the successful use of OMM. Another 1990 study described seven radiological Key words: inferior alveolar nerve (IAN), signs in preoperative x-ray films that were associated with Osteopathic Manipulative Medicine (OMM), Osteopathic an increased risk of IAN injury. These signs were classified Manipulative Treatment (OMT), traumatic neuroma, soft- as root related or canal related. The root-related signs tissue technique, cranial technique, third molar, mandible. include darkening, deflection, narrowing and a bifid apex. The canal signs include interruption of the lamina dura, Introduction diversion and narrowing.5,6 Retrospective and prospective There can be many possible complications in jaw studies were conducted, and only three of the seven signs surgery. Nerve injury can occur following injection of were found to be significantly related to IAN injury in both a local anesthetic, removal of a difficult tooth, or from studies. These included diversion of the canal, darkening of trauma to the jaw and face. During administration of local the root and interruption of the lamina dura.5 anesthetic, the needle has the potential to puncture the nerve sheath, causing paresthesia for days to weeks. The Nerves can be under mechanical load while sliding inferior alveolar nerve (IAN) is especially prone to injury within nerve canals. When the “neural container” is following removal of a lower third molar.1 This nerve damaged and the dynamic protective mechanisms fail, is responsible for sensation in the lower lip, mandibular the corresponding nerve is put at risk for injury, pain and 7 buccal gingivae and dentition. The IAN originates from disability. “Nerve gliding” and “neural mobilization” are the posterior division of the mandibular branch of the techniques used in the treatment of peripheral nerves to trigeminal nerve. This nerve enters the mandible through reduce symptoms following a neurologic injury. A meta- the mandibular foramen and runs directly below the root analysis reviewed neural mobilization techniques and their tips of the mandibular teeth, predisposing it to risk during outcomes, and eight of the eleven studies demonstrated 8 tooth extraction. Temporary IAN injury following lower a positive benefit for their usage. Similar techniques third molar surgery can occur in up to eight percent of have been adapted to aid elsewhere in the body. William cases. Permanent injury can occur in 3.6 percent of cases. Garner Sutherland, DO, developed techniques based on If the third molar is closely associated with the IAN canal, the subtle yet palpable movement found in study of the 9 temporary injury can occur upwards of 20 percent of the cranial bones. One of Dr. Sutherland’s students, Harold I. time and permanent damage between one and four percent Magoun, DO, FAAO, used cranial osteopathic techniques 10-12 of the time.2 to treat dental complaints. Edna M. Lay, DO, FAAO, also described case studies where OMM was used to treat Injury to the IAN during third molar extraction can temporomandibular joint dysfunction.13 result in a traumatic neuroma. Traumatic neuromas are
Volume 23, Issue 2, June 2013 The AAO Journal Page 15 There are many indications for the use of OMM. In control. The patient also received a psychophysiological this case report, OMM was used to directly “address the assessment. Based on the results, it was recommended she muscular and fascial structures of the body and associated start eight weeks of electromyography, skin conductance neural and vascular elements.”14 OMM can also be used to biofeedback and at-home self-hypnosis. relax hypertonic muscles, increase the elasticity of fascia, On the patient’s second visit to PM&R, she had yet to improve circulation and improve abnormal somato-somatic receive baseline labs or MRI. She continued to complain of and somato-visceral reflex activities.14 seven out of 10 jaw pain. Her exam showed a palpable soft- MEDLINE and the Cochrane Databases were tissue prominence less than four millimeters in diameter searched for studies addressing the use of OMM to treat the near where the right IAN enters into the mandibular canal. IAN following dental surgery. The key words listed were This prominence was not palpable on the left and did not used to search within MEDLINE, the Cochrane Library, have the spongy feel of reactive lymph tissue, but felt Cochrane Oral Health Group Trials Register, the Journal of rather fibrous. The prominence was not interdigitated and the American Osteopathic Association and EMBASE are immoveable like a malignancy, but slightly adherent to presented above. No citations were found. surrounding tissue as benign, yet restrictive soft tissue that needed to be freed up in order to restore movement In the following case, a patient with residual jaw pain in the area. The patient was told to continue biofeedback, following remote right third molar extraction was evaluated obtain her MRI and follow-up in one week to begin OMM and treated with OMM. This included the use of cranial and treatment. soft-tissue techniques employed to free restriction, reduce edema and restore normal anatomy and function in the The MRI of the patient’s orbit, face and soft tissues of surrounding area. the neck, with special focus on the right mandible and IAN, showed no masses, abnormal fluid collections, or other Report of Case significant abnormality along the trigeminal nerve per the A thirty-year-old female underwent standard wisdom radiologist. tooth extraction in 2002. Following the procedure, the patient complained of pain and paresthesia along the right On the patient’s third visit, she continued to have inferior alveolar distribution of the mandibular branch seven out of 10 jaw pain with an unchanged physical exam. of the trigeminal nerve. Over the course of 10 years, the She still had the four-millimeter soft-tissue prominence patient visited the dental clinic on eight separate occasions that was roughly the consistency of the surrounding tissue, for right jaw pain and dental pain. but slightly more formed. The patient confirmed palpation of this prominence reproduced her pain. At this time, The patient’s dentist examined her and noted fair consent was obtained for intraoral soft-tissue manipulative oral hygiene and the absence of third molar teeth, caries or techniques. The goal in using these techniques was active periodontal disease. Dental bitewing four-view x-ray to normalize the surrounding anatomy, free any scar films showed no radiographic evidence of oral infection or tissue, reduce any fluid accumulation and allow the IAN osseous abnormality. No source for the patient’s jaw pain an unrestricted path through the mandible. Following was identified. manipulation, the patient’s pain was instantly reduced to The patient’s primary care physician prescribed three out of 10. A cervical spine x-ray was ordered to rule Gabapentin for her jaw pain. Within the same month, out any cervical pathology and clear the patient for cervical the patient made her first appointment with our Physical OMM. Medicine and Rehabilitation clinic (PM&R). At this On the fourth visit, the patient’s review of symptoms appointment, she said she was not feeling any relief with (ROS) and exam remained unchanged. The patient’s Gabapentin, but did feel occasional relief with Ibuprofen. cervical spine film was interpreted as normal. Use of She continued to rate her pain at seven out of 10. The intraoral OMM successfully reduced the patient’s post- patient denied having any allergies or the use of any treatment pain score to zero out of 10. In addition, high tobacco products or illegal drugs. She did report occasional velocity low amplitude (HVLA) OMM corrected her alcohol consumption. Her medical history included asthma, cervical somatic dysfunction of C4ERrSr and C3ERlSl. migraines, knee arthralgia, low back pain, carpal tunnel syndrome, and a 10-year history of recurrent jaw pain. On the fifth visit, the patient presented complaining of three out of 10 pain. Cranial examination revealed multiple At this time, it was suggested that the patient obtain somatic dysfunctions of her cranial bones, including a magnetic resonance imaging (MRI) to further evaluate her right sphenoid torsion, and right temporal restriction. jaw pain. Other recommendations included biofeedback Decreased motion was present in her right maxilla, as well therapy, use of a transcutaneous electrical nerve stimulation as increased tone in her right lateral pterygoid and right unit and consideration of Tramadol as needed for pain
Page 16 The AAO Journal Volume 23, Issue 2, June 2013 medial pterygoid muscles. Following OMM, the patient’s extraction. The success of the treatment was defined by the jaw pain was reduced to two out of 10. patient’s report of successive post-treatment pain scores of zero out of 10 for the first time in 10 years. Her pain scores On the sixth visit, the patient presented with three out remained at zero out of 10 for four straight months. The of 10 right jaw pain and an otherwise unchanged ROS and successful treatment was directed primarily at normalizing exam. Similarly, OMM was used and reduced the patient’s the anatomic relationships near the entry point of the IAN post-treatment pain score to one out of 10. into the mandible and resulted in palpable improvement, On the seventh visit, the patient presented with zero which objectively coincided with the patient’s subjective out of 10 pain with an unchanged exam that still showed a self report of complete pain relief. soft-tissue prominence on the right that was not present on References the left. Post-OMM treatment, the patient’s pain remained at zero out of 10. 1 Holland DJ. Complications in exodontia and oral surgery. Oral Surg Oral Med Oral Path. 1948;1(8):758-778. On the eighth visit, the patient presented with zero out 2 Renton T. Prevention of iatrogenic inferior alveolar nerve injuries of 10 pain and an unchanged exam from her previous visit. in relation to dental procedures. Dent Update. 2010;37(6):350-352, She stated she felt much better and continued to report a 354-356, 358-360. post-treatment pain score of zero out of 10. 3 Gilchrist JM, Donahue JE. Peripheral nerve tumors. In: Shefner JM, ed., Maki R, ed., Eichler AF, ed. Up to Date. Waltham, MA: On the ninth visit, the patient continued to report zero Wolters Kluwer Health; 2013. out of 10 jaw pain. However, examination of the mucosal 4 Peszkowski MJ, Larsson A. Extraosseous and intraosseous oral surfaces was equal, without any soft-tissue prominences traumatic neuromas and their association with tooth extraction. J Oral Maxillofac Surg. 1990;48:963-967. bilaterally. The patient did complain of neck tightness and was diagnosed with cervical somatic dysfunction of 5 Rood JP, Nooraldeen Shehab BAA. The radiological prediction of inferior alveolar nerve injury during third molar surgery. Br J Oral C5ERlSl and C3ERrSr. This was successfully treated with Maxillofac Surg. 1990;28:20-25. cranial, Muscle Energy and HVLA techniques. The patient 6 Smith AC, Barry SE, Chiong AY, Hadzakis D, Kha SL, Mok remained at zero out of 10 pain following treatment. SC, et al. Inferior alveolar nerve damage following removal of mandibular third molar teeth. A prospective study using panoramic Several months later, the patient remained at zero radiography. Aust Dent J. 1997;42(3):149. out of 10 pain with no ROS changes and a normal exam. 7 Shacklock MO. Neurodynamics. Physiotherapy. 1995;81:9-16. Having a pain-free, normal exam over the course of four 8 Ellis RF, Hing WA. Neural mobilization: a systematic review months for the first time in 10 years, she was considered of randomized controlled trials with an analysis of therapeutic successfully treated with OMM and discharged to her efficacy.J Man Manip Ther. 2008;16:8-22. primary care physician. 9 Sutherland WG. The Cranial Bowl. 1944. J Am Osteopath Assoc. 2000;100(9):568-73. Discussion 10 Magoun HI. Osteopathic approach to dental enigmas. J Am Traumatic neuromas are an uncommon occurrence Osteopath Assoc. 1962;62:34-42. in dental procedures.6 Surgical excision is one treatment 11 Magoun HI. Dental equilibration and osteopathy. J Am Osteopath option.3 As with all surgeries, though, there are risks. Assoc. 1975;74:115-125. Sometimes surgery is not even an option. Our patient, with 12 Magoun HI. The dental search for a common denominator in normal dental examinations and negative imaging, was craniocervical pain and dysfunction. J Am Osteopath Assoc. not a surgical candidate. She had few options available 1979;78:83-88. besides continued use of pain-relieving medications, which 13 Lay EM. The osteopathic management of temporomandibular joint dysfunction. In: Gelb H, ed. Clinical Management of Head, Neck had provided her minimal benefit.In the past, the use of and TMJ Pain and Dysfunction: A Multidisciplinary Approach to drugs was directed at a presumptive diagnosis of IAN Diagnosis and Treatment. Philadelphia: W.B. Saunders; 1985. nerve injury, which was not yet apparent on imaging. In 14 Chila AG, ed. Foundations for Osteopathic Medicine. 3rd ed. this case, the use of OMM provided complete pain relief Philadelphia: Lippincott William & Wilkins; 2010: 763–764. without the side effects inherent in pharmacologic therapy. The palpable soft-tissue change remained unclassified. Accepted for publication: May 2013 The disappearance of the soft-tissue change coincided with Address correspondence to: the patient’s report of complete pain relief following the James A. Lipton, DO, FAAO, FAAPMR successful application of OMM. Dept. of Rehabilitative Medicine Services Veterans Administration Hospital Conclusion 100 Emancipation Drive The use of OMM was successful in the treatment Hampton, Virginia 23667 of persistent jaw pain resulting from lower third molar [email protected]
Volume 23, Issue 2, June 2013 The AAO Journal Page 17 Prolotherapy Weekend
October 10-12, 2013, at UNECOM in Biddeford, ME
Course Outline Course Directors Thursday, October 10, 5:00 pm - 10:00 pm: Physicians who Mark S. Cantieri have not taken a prior course in prolotherapy are required to attend this session. It will include an introduction to of Osteopathic Medicine,, DO, FAAO, and isis aboard 1981 prolotherapy, wound healing, degenerative postural cascade, graduate of Des Moines University College coding and billing. various hospital staffs as a consultant in certi�ied in NMM/OMM. He has served on Friday and Saturday, October 11-12, 8:00 am - 5:30 pm: OMM—treating newborns, post-operative Participants will be divided into two groups—beginners and patients and patients in intensive care units. advanced. These two groups will alternate between lectures He currently operates a private practice, in anatomy and injection technique, and time in the anatomy lab performing injections under supervision and reviewing specializes in the treatment of chronic musculoskeletal pain. prosections. Corrective Care, PC, in Mishawaka, IN, which of the AAO. Principles of Prolotherapy Dr. Cantieri is a Past President and former Secretary-Tresurer and Ravin TH, will serve as the course syllabus. Please see George J. Pasquarello graduated http://principlesofprolotherapy.com/index.htmlby Cantieri MS, Pasquarello for details. GJ NMM/OMM, he has served, DO, as FAAO, a Residency Prerequisites from UNECOM in 1993. Board-certi�ied in
Participants must indicate upon registration whether Program Director and Associate Professor Functional anatomy: (1) Level I course or equivalent. they are a beginner or advanced prolotherapy student. If of OMM at UNECOM. He has also worked Heas a is clinical currently specialist in private at Maine practice Spine at East & Rehabilitation and University Healthcare. youCME are unsure, please contact Sherrie Warner at the AAO. 20 hours Greenwich Spine & Sport in East Greenwich, Course Location Travel Arrangements RI. Dr. Pasquarello is a Past President of the AAO. of AOA Category 1-A credit is anticipated University of New England College of Osteopathic Medicine
A rental car is recommended since the campus is located Call Tina Callahan of Globally Yours Travel at (800) 274-5975. 11 Hills Beach Road Biddeford, ME 04005 about 15-20 minutes from most hotels and restaurants. (207) 283-0171 Registration Form Registration Rates Prolotherapy Weekend � Principles of Prolotherapy October 10-12, 2013 � Principles of Prolotherapy $1,500 - I already own a copy of Name: ______AOA#: ______I am$1,810 a � -Beginner Please order � Advanced me a copy of prolotherapy student. Nickname for Badge: ______Please notify us of any special dietary restrictions.
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Please submit registration form and payment viaClick mail hereto the to American view the Academy of Osteopathy,® 3500 DePauw Blvd., Suite 1080, Indianapolis, IN 46268 or by fax to (317) 879-0563. Or register online at www.academyofosteopathy.org
Page 18 The AAO Journal Volume 23, Issue 2, June 2013 In the hands of an angel
Jamie B. Archer, DO (UK)
In 2009, I finished work on a replica of Dr. A.T. Still’s treating chair.1 This chair was invented and designed by the old doctor to aid osteopaths in treating their patients. I travelled to Kirksville, MO, with the chair and demonstrated its use during the Founder’s Day celebrations at A.T. Still University. The chair was then donated to the Museum of Osteopathic MedicineSM in Kirksville, where it can be seen today. Another of Dr. Still’s inventions then began to intrigue me—the so-called Saint’s/Angel’s rest, which he used for relief when suffering from headaches. Dr. Still, as far we know, was a chronic headache sufferer, first experiencing headaches as a young boy. In his autobiography, he describes what he calls his first discovery in the science of Osteopathy (Figure 1).
Figure 2. Head in swing (Murray 1918)
Figure 1. The first lesson/discovery in Osteopathy (Still 1897)
One day, when I was about ten years old, I suffered from a headache. I made a swing of my father’s plow-line between two trees; but my head hurt too much to make swinging comfortable, so I let the rope down to about eight or ten inches of [sic.] the ground, Figure 3. Dr Still and Elbert Hubbard. The rest can be threw the end of a blanket on it, and I lay down on seen on the treatment table next to the hat (Hubbard 1912). the ground and used the rope for a swinging pillow. Thus I lay stretched on my back, with my neck across the rope. Soon I became easy and went to sleep, got Dr. Still did this for himself because, as every up in a little while with the headache all gone.2 osteopath knows, it is virtually impossible to treat oneself. His ever-increasing workload also meant he Dr. Still goes on to say that he followed this method could not always see every patient. Some of these original for twenty years before he really understood how it worked. rests survive today and can be seen in the Museum of However, suspending a rope (Figure 2) is not always Osteopathic Medicine.SM practical or easy (especially between two trees), and Dr. Still soon found that a portable device was more ideal. As with the old doctor’s treating chair, I wanted to (Similar-looking devices have been found in other cultures know what they actually felt like to lie on and how they stretching back hundreds of years.) Over a number of worked. However, the original rests are very fragile and years, he designed and built many versions based on the trying them is out of the question. So the only thing for rope design, both for himself and for some of his patients me to do was try to make working replicas. I chose three (Figure 3). different designs, and my colleague Jason Haxton, Director
Volume 23, Issue 2, June 2013 The AAO Journal Page 19 of the Museum of Osteopathic Medicine,SM and Debra wrong way around and, in fact, the long feet acted more as Loguda-Summers, Curator, kindly provided me with a counter weight (Figure 5). Trying this position, the rest detailed photographs of the delicate originals, along with felt much more comfortable and many of my patients, who appropriate measurements. I then set about making them in I asked to try it, agreed. Had my two-year-old worked it my spare time. What follows is the outcome of my efforts. out? Maybe— it certainly felt right. Saint’s Rest 1 Saint’s Rest 2 This rest is made out of two, roughly L-shaped pieces The next rest is also made of wood. The design is of wood attached to a central block in the middle. The feet simpler, in that the base of the headrest is flat, but set at an are approximately 40 centimeters in length and flatten out incline (Figure 6). The two wedges of wood mounted on into a smooth paddle shape at the point. The thick, vertical the base are set about four centimeters apart and curved supports are set at an angle away from the horizontal and to accept the back of the skull. To prevent pressure on are flat at the top. This top has a thick piece of leather the cervical and occipital regions from becoming too attached with metal pins and cut to the shape of the occiput uncomfortable for the patient, a small piece of leather has to support the head (Figure 4). been tacked on the wedges to form a crude sling on which the patient can rest his/her head (Figure 7).
Figure 4 Figure 6 Initially, it was thought the patient was to lie with the horizontal arms running down and pressing on either side of the spine, and the head resting on the leather support. I assumed it was designed to somehow affect/inhibit the upper dorsal nerve centers that influence circulation in the head, as well as free any constriction in the chest, much like Dr. Still’s croquet ball design.3 However, this felt incredibly uncomfortable, and I was certain Dr. Still would not have designed something so awkward. I checked the measurements, and they were right, so I was stumped. Figure 7
In terms of comfort, this design exceeds the previous one, allowing the patient to experience potentially greater relief. The pressure from the wooden wedges appears to rest right in the region of the transverse processes of the atlas and upper cervical segments. These particular points are highlighted by Dr. Still when treating patients suffering from a headache.4 Saint’s Rest 3 Figure 5 The final rest was very much a reflection of the rope between two trees. However, in this case, a belt is Then, my two-year-old son, who had been watching suspended between a metal frame (Figure 8). As seen in the me, lay down, slid the feet of the rest under my desk photographs, a self-supporting, flexible metal frame was so they were anchored, and put his head on the leather made and a custom replica of the gun belt Dr. Still used support. It was then I thought I may have been using it the was slung over each end. The belt (minus the cartridge
Page 20 The AAO Journal Volume 23, Issue 2, June 2013 loops) is attached to the frame with Chicago screws and is of the neck over the occipital nerves. Here I bring a gentle buckled underneath (Figure 9). The slack in the belt can and firm pressure for a few minutes, during which time I be taken up by simply tightening or loosening the buckle, find the muscles relaxing under my fingers on both sides exactly as would be done if it were holding up a pair of of the neck, from the base of the skull to the fifth cervical trousers. The family, friends and patients who have all tried vertebra.4 this design agree it is the most comfortable of the three, The neck and sub-occipital region is clinically commenting that there is more of a feeling of suspension in very important to osteopaths, both mechanically and this design, rather than compression from the wood in the physiologically, and therefore demands our greatest respect. others (Figure 10). For example, cardiac and vasomotor centers are found in this region, and their role in helping control and coordinate circulation through the cranium and the rest of the body is vital. In addition, there are various attachments for the many layered cervical fascia as it extends downwards from the skull, enveloping the neck, heart and diaphragm, and further linking the head and neck with respiration and circulation (Figure 11). Figure 8
Figure 9
Figure 11. The continuation of the cervical fascia (Goldthwait 1934)
The deep and superficial cervical and occipital tissues are numerous, and their relationship with the dura and external scalp tissues is critical to understand. In addition, this region allows the passage of delicate neurovascular Figure 10 structures, which are most accessible to the delicate hands of osteopaths, in particular the great wandering or vagus nerve as it begins its long and busy journey down through When using these three replica rests, it is worth the body. Therefore, pressure from Dr. Still’s rest, much bearing in mind they were made using the measurements like pressure from our own hands, may begin to calm any taken from the originals in the museum. Dr. Still made aberrant afferent input, and settle the sympathetic nervous many different versions of the same and different designs. system, helping to open up circulation, inhibit occipital He also made rests for patients, so it is plausible these nerves, affect fluid motion and reduce tissue tension around rests are designed to fit someone else’s anatomy. Dr. Still’s delicate neurovascular structures. This would help to ease own head was very asymmetrical, which may be why many uncomfortable and distressing conditions. some individuals trying them feel they are uncomfortable.5 However, this is easily remedied, as rests can be made to fit From the very beginning, the founders of our an individual’s anatomy. profession understood, respected and worked with this body unity, and those who care to delve into the rich Can it help? archive left for us will find countless references to it. For continued or periodic headaches, I begin in every Dr. John Martin Littlejohn, a pupil of Dr. Still and first case at the occiput, by laying my fingers flat on the back
Volume 23, Issue 2, June 2013 The AAO Journal Page 21 Dean of the American School of Osteopathy, reminds us 2 Still AT. Autobiography of Andrew Taylor Still with a History of that, in terms of embryology, the head is an outgrowth of the Discovery and Development of the Science of Osteopathy. Kirksville, MO: Published by the author; 1897. the cervical region of the spinal cord—the anterior cord becomes the brain and the anterior column the cranium. 3 Still CE. Frontier Doctor, Medical Pioneer: The Life and Times of A.T. Still and His Family. Kirksville, MO: Thomas Jefferson Therefore, the cervical region maintains the position of University Press; 1991. mediator between the brain and the rest of the nervous 4 Still AT. Osteopathy: Research and Practice. Kirksville, MO: system below the cervical region throughout adult life. This Published by the author; 1910. means osteopaths may look for lesioning/dysfunction in the 5 Sorrel M. Charlotte Weaver: Pioneer in Cranial Osteopathy. cervical region involving any part of the head or brain, or Indianapolis, IN: The Cranial Academy; 2010. involving any part of the body organism, even down to the 6 Littlejohn JM. Principles of Osteopathy. Published privately by the extremities.6 author; 1907. 7 Goldthwait J, Brown L, Swaim L, Kuhns J. Body Mechanics in However, like Dr. Still’s treating chair, the Saint’s the Study and Treatment of Disease, Philadelphia: J.B. Lippincott Rest is merely an aid, and can never replace an intelligently Company; 1934. applied osteopathic treatment given by a physician who 8 Hubbard E. A Little Journey to the Home of Andrew Taylor Still. fully understands osteopathic principles. The next time you New York: The Roycrofters; 1912. are in Kirksville, please take time to visit the museum and 9 Murray CH. The Practice of Osteopathy: Its Practical Application view the amazing exhibits and artifacts it has. Also try the to the Various Diseases of the Human Body. 5th Ed. Elgin IL: Saint’s Rests; I would be interested in your comments. Published by the author; 1918. Acknowledgements Accepted for publication: May 2013 Special thanks to Jason Haxton, Director of the Address correspondence to: Museum of Osteopathic Medicine,SM and all the friendly, Jamie B. Archer, DO (UK) helpful staff. Alma Osteopathic Practice 10 Holmgate Road, References Clay Cross, Chesterfield 1 Archer J. Dr. A.T.Still’s Treating Chair. The American Academy of Derbyshire, S45 9PH, UK Osteopathy Journal. 2009;19(4):9-12. [email protected]
Lighting the Flame of Knowledge.
Philadelphia College of Osteopathic Medicine (PCOM) brings to light a rich tradition of excellence in education and leadership. Currently, the Georgia Campus—Philadelphia College of Osteopathic Medicine, in the greater Atlanta area, has the following exciting positions available: Faculty Position: Department of Osteopathic Manipulative Medicine Full time faculty position in the Department of Osteopathic Manipulative Medicine. This individual will be expected to teach osteopathic medical students in both lecture and laboratory sessions in all four years of the curriculum, see patients and develop an outpatient clinic for M-3 month long rotation, plan and supervise OMM Inpatient Student Service, assist in preparation of OMM video clips and tutorials, participate in existing research and initiate new OMM research, assist in planning and production of new publications, and assist in planning and supervision of the OMM Residency. The successful applicant will have a D.O. degree and proficiency in osteopathic manipulative medicine. The candidate needs to have or be eligible for a license to practice Osteopathic Medicine in the State of Georgia. Board Certification or eligibility by the AOBNMM or AOBSPOMM is required. Additional Board Certification or eligibility by the AOBFM is desirable. The review of applications will begin immediately and continue until the position is filled. Salary for this position will be commensurate with experience and qualifications. Clinical Education Coordinator Seeking qualified Osteopathic Physician for a full-time Clinical Education Coordinator. This full time position reports to the Chair of Undergraduate Clinical Education. This individual will be responsible as the Director of the Advanced Clinical Skills Program. He/She will supervise the Clinical Adjunct Facultyís participation in the didactic educational programs and assist the Chair in management of the Clinical Clerkship program. Minimum of five years in a clinical practice. Experience in clinical education as a Clerkship Director, Program Director, Didactic Educator, or similar activities. Must be Board Certified in a Primary Care specialty. To apply for these positions, send via E-mail a personal statement describing interest in and qualifications for this position, a curriculum vitae, and names and addresses of three references, preferably from current or former supervisors. All inquiries must include salary requirements and should be directed to: Department of Human Resources, GA-Campus, 625 Old Peachtree Road, Suwanee, GA 30024. Call (678) 225-7515; Fax (678) 225-7519; Email: [email protected] EOE WWW.PCOM.EDU
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Counterstrain is a powerful tool to treat chronic and acute pain. Its gentle but logical manipulations can affect immediate, COMPENDIUM EDITION often lasting relief, and help maximize the body’s natural inclination toward health. Actual case histories and standardized, muscle- Clinical Application of COUNTERSTRAIN
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Building on the educational and clinical impact of Dr. Myers’ original work, Clinical Application of Counterstrain (2006 Osteopathic Press), the Compendium Edition includes contributions from scholars and practitioners who work, practice or teach around the world: William H. Devine, DO, Medical Editor; Christian Fossum, DO (UK), “From Theory to Practice;” Richard L. Van Buskirk, DO, PhD, FAAO, “Physiology of Somatic Dysfunction;” Michael L. Kuchera, DO, FAAO, “Differential Diagnosis of Myofascial Points;” Randall S. Kusunose, PT, OCS, “Cranial Counterstrain.” Foreword by the author’s colleague and friend, Dr. Andrew Weil, MD. Now in hardcover for durability.
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Volume 23, Issue 2, June 2013 The AAO Journal Page 23 The liquorodynamic model of the primary respiratory mechanism
Yuri E. Moskalenko, DSc., DO (Hon.); Tamara I. Kravchenko, PhD, DO; Gustav B. Weinstein, PhD; Terence C. Vardy, DO
The “Primary Respiratory Mechanism” (PRM) is a problem is to determine the forces which could provide an term and fundamental concept that has been used for more impulse causing an overflow of spinal liquid in the caudo- than 80 years in osteopathic medicine. Until recently, the cranial direction, thus forming the CRI, and initiating the PRM was not a standard term for describing an organized motion of the skull bones. One must also consider what physiological mechanism, and there was no clear idea of its forces could initiate the return of liquid in a cepahalic- physiological importance. caudal direction and create conditions for a new cycle of the PRM. In Cranial Osteopathy in the beginning of the twentieth century, the summary data from several different From a physiological viewpoint, only the muscular researchers generalized the PRM as the Cranial Rhythmic system can be the force initiating the PRM. There could Impulse (CRI) and as based on frequency. This was also be two types of forces related to the CSF. First, the based on periodic physiological processes ranging from cardiovascular system as a whole could be responsible two to 30 cycles per minute, as shown in the data provided. for the movement of liquids, and thus define CSF activity. In this generalization, various conceptualized models In the skull cavity, the CSF is determined by the arterial regarding the origin of the CRI have also been expressed. pressure and pulse motion of the arterial vessels, combined with changes in the regional volumes of blood due to Some of these concepts are now thought of as changes in the tone of the brain blood vessels. improbable with our knowledge of modern biomechanics and biophysics. Others are more realistic and demand Second, contractile structures (essentially serious analysis as to the genesis of the CRI from a paravertebral muscular structures) located outside the scientific and quantitative perspective. Due consideration craniospinal cavity may affect the PRM. These may be the has not been given to the physiological sources defining source of forces that direct movement of the lymph and this phenomenon. The factors frequently listed as can influence the mobility of a liquid. Electrical forces participating in the formation of the CRI and the PRM, are and electromagnetic fields may also act as factors in liquor unfortunately considered separately. Another idea is that movement. Other mechanical and physiological factors they are the interaction of two separate mechanisms in an may be considered, too.2 intricate, combined process. There are a number of conceptual models regarding More realistic ideas as to the origin of the PRM are the nature of the PRM due to the complexity of this given in a recently published monograph,1 which includes phenomenon. To truly consider the nature of the PRM, it is a description of the phenomenon based on the mobility of necessary to look carefully at each of the proposed models the skull bones. It is defined by the ratio of the volume of mentioned previously, and determine if there is a source liquid in the craniospinal space and possible overflow of of all these physical forces that is capable of providing an cerebrospinal fluid (CSF) into the spinal cord. One model overall mechanism for interchanging movement of the CSF considers the primary link in the chain of phenomena and blood. described as the PRM to be the CRI, which actually With the new data as measured by our current represents a very short period of time, but the intensive equipment and advanced computer capabilities, it is inflow of liquor to the skull cavity. This in turn causes an now possible to reappraise our ideas of the PRM and its increase of intracranial pressure (ICP), and thus initiates the structural and functional organization. processes resulting in the PRM. Methods However, it is not yet clear what actually constitutes the CRI. There are many different points of view, even It is known that the basic mechanism of PRM mystical representations. A more realistic approach to the liquorodynamics is in the craniospinal cavity, and is
Page 24 The AAO Journal Volume 23, Issue 2, June 2013 defined by a combination of physical forces influencing much more primitive measuring equipment in experiments the liquorodynamics. This occurs in a strict sequence on animals.3 These results were only recently repeated on of space and time. It is necessary to establish adequate humans with significantly modernized equipment,4 and methodology to determine the PRM. The most effective indicate the existence of the opposite movement of liquor is the combination of Transcranial Dopplerography streams to both the head and lumbar regions alternately. (TCD – DWL, Germany) and a new method of Further study of this phenomenon, by placing four Rheoencephalography (REG – Mitsar, SPb). This pairs of electrodes on the head (bi-temporally), cervical, impedance REG signal is based on simultaneous use at thoracic and lumbar levels of the vertebral column, showed three frequencies, allowing the measurement of a particular that, from each pair of electrodes, it is possible to observe liquor component for a registered signal, and thus revealing factors related to the PRM. This measurement combination, together with an electrocardiogram and chest respiratory movements through a transformer (PowerLab-4 – ADInstruments, Australia), has program opportunities (Chart-5) allowing calculation of the amplitude phase and spectral analysis of the registered signals. Because the optimal quantification for CRI and PRM investigations are not known, the maximal possible quantization—128kHz—was initially used. Research was conducted with 18 healthy young adults (18 to 24 years old) in a comfortable, relaxed horizontal position. TCD was registered at the base of the middle cerebral artery. Results and Discussion To consider the primary mechanism of the PRM, one must take into account all the liquor streams of the entire craniosacral system. For this purpose, we placed REG Figure 2. Simultaneous registration of rheoencephalogram from four pairs of electrodes placed along the cranio- vertebral system to observe the liquorodynamics in different parts of the craniospinal cavity.
two features of comparative changes of REG (Figure 2). One (Figure 2, right section) shows there is some delay between the measurement points at the beginning and peak of the pulse waves. Thus, there is a time delay of a pulse wave in liquor movement from the head to the lumbar vertebral region. The time delay of the pulse wave is approximately 0.6 to 0.8 seconds along the length of the craniospinal cavity, from the head downward along the entire spinal cavity. Figure 1. Simultaneous registration of rheoencephalogram at the head and lumbar region of the vertebral column. This corresponds to data provided by means of longitudinal magnetic resonance imaging (MRI) in the electrodes—two on each side of the spinous processes— sagittal plane, where consecutive pulse movements of some 4 simultaneously on the skull (bi-temporally) and at the portion of spinal liquid in the cranio-caudal direction are lumbar level of the vertebral column. The recordings visible. Therefore, it is logical to conclude that shifts of (Figure 1) showed that both pulse changes and slow waves pulse waves of REG in the vertebral column correspond of the REG were inversely related. to movement of pulsating “portions” of liquor in the same direction. The small, inversely related shifts indicate reciprocal liquor overflows in both the caudal and cephalic directions. The second observation is that the periodical This measurement was first observed in 1957, but with (following eight- to 15-second) shifts in groups of pulse
Volume 23, Issue 2, June 2013 The AAO Journal Page 25 waves in the caudo-cranial direction (Figure 2, left section), However, these forces are insignificant. The heart and the number of pulse waves from level to level in such a systole stroke action provides the skull with approximately “package” decreases while their size conversely increases. 20 percent of heart stroke volume (about 10 ml). Most In other words, shifts of these “packages of pulsations” in of this volume is distributed in the skull cavity, and, the caudo-cranial direction are observed. These movements according to nuclear magnetic resonance, only about two begin in the lumbar part of the vertebral column for 1.2 to three ml of liquor is forced out into the spinal cavity. to two seconds until they reach the thoracic level, for the This size can vary under different conditions. In particular, following one to 1.5 seconds up to the cervical level, and it depends on body position. Sufficient liquor volume between 3.5 to five seconds reaching the skull. must accumulate for CRI emergence or initiation, and this takes a period of seconds. It is possible that the process of With each “package” of pulsations, 10 to 15 milliliters liquor accumulation in the lumbar region is initiated by (ml) of liquor is delivered into the skull over four to six gravitational movement in the caudal direction, in addition seconds. These studies show there are two simultaneous, to an increase in pressure due to its actual production.11,12 counter-directed streams of liquor. As a result, for some seconds, liquor volume sufficient This data allows us to conclude that these “packages” for CRI initiation builds up in the lumbar region. While of pulsations represent the CRI. The CRI may then cause this process can vary over a wide range depending on movement of the skull bones and reciprocally support specific conditions, it corresponds to the average pulsating the CRI. The measurements were made to quantitatively frequency of the CRI.2 assess the true amount of intracranial volume changes, If the process of liquor accumulation in the lumbar and if they are capable of causing the skull bones to region and the forces involved are explainable, the forces move.5,6,7,8 It was shown that the size of intracranial liquor responsible for liquor flowing in the cranial direction volume fluctuations constituted 0.6 to 1.2 percent of the remain unclear. This question is important to answer for total volume in a healthy person, and are on average an accurate explanation of such a complex phenomenon six to 15 ml. It was therefore of interest to compare the as the PRM. First of all, it is necessary to emphasize that results of direct intracranial injection of x-ray-contrast the source of forces causing the CRI, arising periodically solution during an angiographic procedure and measure the as fluctuations, is an intensive, short-term stream of liquor movement of the skull bones. in the cranial direction, most likely created outside the The infusion of a fixed volume (20 ml) of such craniospinal cavity. It is difficult to find the necessary a contrast solution into a carotid artery for one second powerful and active contractile structures in this region. creates a shift in the skull bones approximately 2.5 to three However, the caudal region of the vertebral column and times greater than their average mobility under normal sacrum are surrounded by powerful muscles of a tonic type, conditions. From the data collected, the CRI volume is six which could definitely influence vertebral column dynamics to 10 ml under normal conditions. This volume is consistent and cause an increase in liquor pressure in the lumbar with the results of indirect measurements carried out by region. We can postulate that stretching of the lumbar dural means of tilt-table, head-down studies.9 The comparison sac by hydrodynamic forces may result in stretching of of the analyses of measurements using several techniques the surrounding spinal muscles and subsequent reciprocal confirms the above conclusion regarding the total volume contraction. This would cause sacral movement, which in of the PRM. CRI duration, derived from REG data, osteopathic practice is evidenced by external palpation. indicates a volume of 10 ml, lasting three to five seconds Such a viewpoint is not new. More than 25 years ago, and capable of causing resultant mobility of the skull bones this concept was expressed as the source of the forces for as observed in osteopathic manual techniques. movement of liquid located in the cranium .13,14 It revolved The source of forces that are truly capable of forming around the role of the accumulation of cranio-caudal liquor the CRI and causing articular mobility of the skull bones is in the head, causing pulse volumes and subsequently CRI an important question. formation. It is very probable that the contraction of spinal The cranio-caudal stream of liquor corresponds muscles can be initiated by neuro-reflectory mechanisms, with the cranial “portion” of stroke blood volume, and as the spinal dura mater contains a large number of is determined by a liquor pressure gradient along the mechanoreceptors. Their participation in regulating craniospinal cavity. This is created by pulsatile increments system hemodynamics, respiration and liquor pressure is of liquor pressure in the rather rigid skull, while the well known. Therefore, the assumption that, in branches spinal dural sac has significant elasticity. The lumbar of the spinal nerves leaving the spinal cavity through region is cross-sectionally four times more elastic than the intervertebral foramen, there are sensory and motor fibers longitudinal caudal/cephalic direction.10 which, in response to an increase in lumbar pressure, can
Page 26 The AAO Journal Volume 23, Issue 2, June 2013 stimulate contractile paravertebral and parasacral muscles15 promotes and accelerates the evacuation of brain waste seems logical. products to the brain sinuses, where they are passed into the blood. In turn, by stimulating the sacral and lumbar musculature, the sacral movement induced is capable of The complexity of the caniospinal cavity’s causing liquor to move in a cephalic direction.12,15,16 Thus, organization and the tissues involved are extremely the caudal spinal muscular system can be a source of forces important for the whole organism, and it can be reasonably forming the CRI. The initial cause for this mechanism is suggested that the PRM plays a significant, but not fully the increase in lumbar pressure and stretching of spinal understood, role. Important correlations have already been dura mater, which in itself can stimulate the actual vertebral established. The PRM significantly changes during the segments and influence their muscular neurological reflex application of some osteopathic manipulative techniques, by stimulation of the dural mechanoreceptors. particularly biodynamic techniques, and with extended periods of a subject in a head-down body position. The Thus, the Primary Respiratory Mechanism may be PRM can sometimes nearly disappear for some periods considered a complex physiological process in which the of time and reappear again later. Activity of the PRM is following four consecutive processes participate: usually suppressed or disappears entirely during a surgical 1. Accumulation of liquor in the lumbar region of anesthesia,17 but increases during a time of emotional or the vertebral column due to the accumulation of physiological stress, as observed when training astronauts increased volumes of liquor from intracranial pressure on a centrifuge.18 during the pulsation phases. This is apparently the When studying any significant physiological result of a rising pressure gradient in the caudal phenomenon, there is always the question of measuring it. direction created by the process of increased liquor In the case of the PRM, it is possible to ascertain absolute production. units. However, for a more accurate assessment of the 2. Deformation of the lumbar spinal dural sac and the PRM, it is expedient to utilize certain relative measurement sacrum due to stretching of the muscles surrounding increments, which can be used for analysis and allow the lumbo-sacral joint system. mathematical calculation of their dynamics to determine 3. Contractions of the muscles surrounding the lumbo- changes in the organism. As illustrated above, for an sacral joint resulting in sacral motion. Increase of assessment of the PRM, it is practical to use the average liquor pressure in the lumbar region and consequent frequency and wave size, which can be expressed by the CRI formation. average number of cycles per minute for a time period of 70 to 90 seconds. 4. The CRI moves along the spinal cavity in a cranial direction by decreasing changes in liquor The amplitude of the mobility of the liquid contents pressure. The liquor flows upward into the skull, in the cranium can be regarded as another indicator. It is causing motion of the skull bones to occur. During effective to non-invasively measure this indicator by means this process, the brain membranes serve as a passive of impedance REG, which depends on such features as the modulator. position of the electrodes. The analysis may be expressed relative to units of pulse volume, as this also minimizes Each of the phases listed above is not the single data collection and measurement errors. In osteopathic causative component. Therefore, the duration and size of practice, there is still evaluation of PRM forces by manual each phase and pulsation can vary. This explains the fact palpation. In principle, it would be possible to create such that the data collected by different researchers to describe a palpatory measurement device, but it would be difficult the origin of the CRI and its frequency varies significantly. to make exact measurements of the counteraction of the In analyzing the functioning of any physiological CRI. Measurements would, in any case, be limited to mechanism, it is always expedient to raise the question of the average frequency and the maximum deviation as a its importance in the overall function of the total organism. ratio between the intracranial liquid components. The The PRM is the primary mechanism controlling the change in frequency of the CRI and its amplitude can be organism’s functionality. The PRM is constantly renewing obtained from spectral analysis using the Сhart-5 software the liquor streams that control craniospinal liquor, and its as transformed by PowerLab-8. An example of such physical parameters can be modulated quickly within the analysis is shown in Figure 3, where the REG recordings entire craniospinal cavity. Considering the reabsorption are accurately visible as both pulse and respiratory waves. of liquor happens mainly by Pacchionian bodies, it is The periodic pulsations of two to four pulse waves may be reasonable to consider that this activity of the PRM regarded as indications of PRM activity.
Volume 23, Issue 2, June 2013 The AAO Journal Page 27 It should be noted that similar phenomena have 21st century at the Sechenov Institute of Evolutionary been observed previously with multiple REG recordings. Physiology at the Russian Academy of Sciences, in However, they have usually been regarded in the category cooperation with Viola M. Frymann, DO, FAAO, Director of recording elements connected with other physiological of the Osteopathic Center for Children in San Diego, CA.) processes, i.e, eye movement. Only in this research was An obstacle for a measurement device of the PRM it determined that the measurement displayed was of is the fact that slow-wave processes in the craniospinal an actual intracranial nature. For an assessment of the cavity are caused by a number of factors, which are in turn amplitude of the PRM, REG analysis was used, and the connected with the functioning of the cerebral vasculature scale of the ordinates of the spectral chart normalized and intracranial pressure, as well as with brain metabolism by pulse amplitude (average size was accepted as a as a whole. Therefore it is not simple to measure PRM in measurement unit). From the data presented in Figure 3, a “pure” data collection sample, since the processes listed the amplitude of the PRM varies 0.15 from pulse size at an above are closely linked to PRM activity by their very average frequency of five to six cycles per minute. frequencies. Figure 4 illustrates this concept by showing the spectral analysis of a two-minute fragment of an REG recording taken from both hemispheres, with TCD and respiration in the frequency range of zero to 0.3 Hz.
Figure 4. Spectral diagrams of TCD, REG (bilateral fronto- mastoidal electodes) and chest respiratory movements – two-minute recording fragment with quantification at 128 kHz. Arrows show the peaks on the spectrograms and their maximal frequencies.
One can see in Figure 4 that each of the spectrograms has a number of peaks. The similarity of their origins Figure 3. 25-second fragments of REG, TCD recordings is demonstrated by whether some of them coincide in and chest respiratory movements in a volunteer at rest, and frequency on different spectrograms. In Figure 4, the spectral diagrams of these processes with quantification at vertical line designates the peaks as being a reflection of 128 kHz. the regulatory processes in the central haemodynamics. The peaks are, most likely, a reflection of fluctuations in On the basis of 87 investigations where the amplitude cerebral vessel tone caused by metabolism, and a regional of the PRM was compared with the results of manual ratio of the liquid volume pressure environment in this measurements, the CRI in children eight to 15 years of age brain region. On the REG measurement chart, it is possible varied in frequency, ranging from four to 15 cycles per to allocate a peak by frequency to reflect the CRI, but minute. The amplitude, according to REG measurements, it is noteworthy that it only appears in one hemisphere. was within 40 to 60 percent of the size of the pulsations. The peaks reflecting respiratory movements are clearly (The research was conducted at the beginning of the visible. Figure 4 shows that the spectral analysis of slow-
Page 28 The AAO Journal Volume 23, Issue 2, June 2013 wave processes can be a long-term objective criteria—a 4 Moskalenko YE, Kravchenko TI. Weinstein GB, Halvorson P, measurement of the PRM and other oscillating processes Feilding A, Mandara A, et al. N. Slow fluctuations in cranio-sacral space: Haemo-liquorodynamic concept of an origin. Russian taking place in the craniospinal cavity. Physiol J. 2008;94(4): 441-447. One now has the ability to present the PRM’s 5 Moskalenko YE, Kravchenko TI, Gaidar BV, Weinstein GB, structural and functional organization in coordination Semernya VN, Mitrofanov VF. About periodic mobility of the with a physiological basis that does not contradict any human skull bones. Human Physiology. 1999;25(6):62-70. previously published papers, and, more importantly, 6 Lewandoski MA, Drasby E, Morgan, Zanakis MF. Kinetic system demonstrates cranial bone movements about the cranial structures. adheres to the laws of biomechanics. Naturally, a number JAOA. 1996;96(9):551. of questions still need additional supporting evidence and 7 Moskalenko YE. Physiological mechanisms of slow fluctuations measurements. For example, features of the PRM due to inside the cranium (Part I). La Revue de l Ostéopathie. 2000; cerebrovascular pathology demand special study. It is very 50:4-15. probable there will be new research opportunities that can 8 Moskalenko YE. Physiological mechanisms of slow fluctuations determine, at last, the exact nature of the PRM since the inside the cranium (Part II). La Revue de l Ostéopathie. discussion was started by its original pioneer, Dr. William 2000;51:4-11. Garner Sutherland. 9 Zanakis MF, Zhao H, Schatzer M, Zaza W, Morgan R, Dyer D, et al. Studies of the cranial rhythmic impulse in man using a tilt table. JAOA. 1996;96(9):552. 10 Zarzur E. Mechanical properties of the human lumbar dura mater. Arq Neuropsiquiatr. 1996;54(3):455-460. 11 Magoun HI. Osteopathy in the Cranial Field. 2nd Ed. Kirksville, MO: Journal Printing Co.; 196: 164. 12 Upledger JE, Vredevoogd J. Craniosacral Therapy. Seattle: Eastland Press; 1983: 367. 13 Kappler R. Osteopathy in cranial field.Osteopathic Physician. 1979;6(2):13-18. 14 Norton J. Failure of tissue pressure for palpatory perception of CRI. JAOA. 1991;91:975-994. 15 Ferguson A. Cranial osteopathy: A new perspective. AAOJ. 1991;1(4):2-16. 16 Korr IM. Osteopathy and medical evolution. Holistic Medicine. 1988;l(3):19-26. 17 Moskalenko YE, Weinstein GB, Demchenko IT, Kisliakov YY, Figure 5. Spectral functions of REG, TCD, respiration and Krivchenko AI. Biophysical Aspects of Cerebral Circulation. ECG obtained with quantification by four kHz (fragmentof Oxford: Pergamon Press; 1980: 165 REG recording – 160 seconds). It can be seen that CRI 18 Vartbaronov RA, Weinstein GB, Moskalenko YE. To a question of and PRM look clearer at lower quantification, as the a ratio of intracerebral and peripheral blood circulation at action of cross accelerations. Proc of Russian Acad Sci. 1969l6:863-869. influences of numerous slow-frequency fluctuations, 19 Moskalenko YE, Frymann VM, Kravchenko TI, Weinstein GB. connected with the cerebrovascular system and brain Physiological background of the cranial rhythmic impulse and the metabolism, are suppressed. primary respiratory mechanism. AAOJ. 2003;13(2):1-33.
References Accepted for publication: May 2013 1 Kravchenko TM, Kuznetsova MA. Cranial Osteopathy: Practical Address correspondence to: Guidance for Doctors. St. Petersburg; 2004;162. Yuri E. Moskalenko, DSc., DO (Hon.) 2 Chaitow L. Cranial Manipulation Theory and Practice: Osseus Institute of Evolutionary Physiology and Biochemistry and Soft Tissue Approaches. London: Churchill-Livingstone; Russian Academy of Sciences 1999: 302. [email protected] 3 Moskalenko YE, Naumenko I. About oscillating motions of CSF in the craniospinal cavity. Physiol J USSR. 1957;3(10):928-933.
Volume 23, Issue 2, June 2013 The AAO Journal Page 29 Osteopathic Approaches to the Heart and Vascular System December 6-8, 2013 at AZCOM in Glendale, AZ
Course Description Program Chair This class will explore the heart and Kenneth J. Lossing, DO, is a 1994 graduate vascular system aspects of neuroregulation, of Kirksville College of Osteopathic Medicine. viscoelasticity and compliance, micro Dr. Lossing completed an internship and perfusion, mechanical tension, function and residency program at the Ohio University dysfunction. College of Osteopathic Medicine. He studied Participants will palpate, diagnose and under the French Osteopath, Jean-Pierre treat the heart muscle, valves, connective Barral, DO, and has become an internationally tissue structures, cardiac coronaries and known speaker on visceral manipulation. Dr. lymphatics, coronary conducting system, cardiac plexus and Lossing is a member of the AAO Board of Trustees. brainstem, as well as sensory and emotional connections. Course Times It will cover the venous system with the superior and infe- Friday, Saturday and Sunday: 8:00 am - 5:30 pm rior vena cava, portal vein, lumbar plexus and sigmoid/rectal Includes (2) 15-minute breaks and a (1) hour-long lunch. plexus. Breakfast, lunch and coffee breaks will be provided It will also address the major visceral arteries of the thorax, _____ I require a vegetarian option head and neck, and upper extremities (aorta, pulmonary _____ I require a gluten-free option vessels, subclavian, common carotid, facial artery, carpal tunnel area, thyroid vessels, internal carotid and breast vessels). Course Location Participants will start cross-correlating osteopathic diagnosis Arizona College of Osteopathic Medicine and treatment with oriental medicine by palpating the 19555 North 59th Avenue, Glendale, AZ 85308 meridians pre and post treatment, and using the “healing (623) 572-3215 sounds.” If time permits, the vessels of the abdomen will begin to be Travel Arrangements covered. Call Tina Callahan of Globally Yours Travel at 1-800-274- 5975. Locals hotels include the Country Inn & Suites in CME Phoenix (1-800-230-4134) and the Quality Inn & Suites in 24 hours of AOA Category 1-A credit are anticipated. Glendale (1-800-230-4134).
Registration Form Registration Rates Osteopathic Approaches to the Heart and Vascular System On or before October 8 After October 8 December 6-8, 2013 at AZCOM AAO Member $ 960.00 $ 1060.00 AAO Non-Member $ 1060.00 $ 1160.00 Name: ______AOA#: ______The AAO accepts check, Visa, Mastercard or Discover payments in U.S. Nickname for Badge: ______dollars Street Address: ______Credit Card #: ______
______Cardholder’s Name: ______City: ______State: ______Zip: ______Expiration Date: ______3-digit CVV#______Phone: ______Fax: ______Billing Address: ______E-mail: ______By releasing your fax/e-mail, you have given the AAO permission to I hereby authorize the American Academy of Osteopathy® to charge send marketing information regarding courses to your fax or e-mail. the above credit card for the full course registration amount. Click here to view the AAO’s Cancellation and Refund Policy Signature: ______
Please submit registration form and payment via mail to the American Academy of Osteopathy,® 3500 DePauw Blvd., Suite 1080, Indianapolis, IN 46268 or by fax to (317) 879-0563. Or register online at www.academyofosteopathy.org
Page 30 The AAO Journal Volume 23, Issue 2, June 2013 AAOJ Submission Checklist
For more information on the elements in this checklist, see “AAOJ Instructions for Contributors” at www.academyofosteopathy.org
Manuscript Submission “Acknowledgments” section with a concise, comprehensive list of the contributions made by individuals who do not Submission e-mailed to AAOJ Interim Scientific Editor at merit authorship credit and permission from each individual [email protected] or mailed on CD-ROM to the AAOJ to be named in print Managing Editor, American Academy of Osteopathy, 3500 DePauw Boulevard, Suite 1080, Indianapolis, IN 46268 For manuscripts based on survey data, a copy of the original validated survey and cover letter Manuscript formatted in Microsoft Word for Windows (.doc), text document format (.txt) or rich text format (.rtf) Graphic Elements Manuscript Components Graphics should be formatted as specified in the “Graphic Elements” section of “AAOJ Instructions for Contributors” Cover letter addressed to the AAOJ Interim Scientific Editor, Kate McCaffrey, DO, with any special requests (e.g., rapid Each graphic element cited in numerical order (e.g., Table 1, review) noted and justified Table 2, and Figure 1, Figure 2) with corresponding numeri- Title page, including the authors’ full names and financial or cal captions in the manuscript other affiliations, as well as disclosure of the financial sup- For reprinted or adapted tables, figures and illustrations, a full port related to original research described in the manuscript bibliographic citation given, providing appropriate attribution “Abstract” (see “Abstract” section in “AAOJ Instructions for Required Legal Documentation Contributors” for additional information) For reprinted or adapted tables, figures and illustrations, per- “Methods” section mission to reprint from the publisher in the AAOJ print and . the name of the public registry in which the trial is online versions accompanied by photocopies of the original listed, if applicable work . ethical standards, therapeutic agents or devices, and For photographs in which patients are featured, signed and statistical methods defined dated “Patient-Model Release” forms submitted
Four multiple-choice questions for the continuing medical For named sources of unpublished data and individuals listed education quiz and brief discussions of the correct answers in the “Acknowledgments” section, permission to publish their names in the AAOJ obtained. Editorial conventions adhered to For authors serving in the U.S. military, the armed forces’ . units of measure given with all laboratory values approval of the manuscript and institutional or military dis- claimers submitted . on first mention, all abbreviations other than measure- ments placed in parentheses after the full names of the Financial Disclosure and Conflict of Interest terms, as in “American Academy of Osteopathy (AAO)” Authors are required to disclose all financial and non-financial Numbered references, tables and figures cited sequentially in relationships related to the submission’s subject matter. All dis- the text closures should be included in the manuscript’s title page. See the . journal articles and other material cited in the “Refer- “Title page” section of “AAOJ Instructions to Contributors” for ences” section follow the guidelines described in the examples of relationships and affiliations that must be disclosed. most current edition of the AMA Manual of Style: A Those authors who have no financial or other relationships to dis- Guide for Authors and Editors. close must indicate that on the manuscript’s title page (e.g., “Dr Jones has no conflict of interest or financial disclosure relevant to . references include direct, open-access URLs to posted, the topic of the submitted manuscript”). full-text versions of the documents
. photocopies provided for referenced documents not ac- cessible through URLs
Volume 23, Issue 2, June 2013 The AAO Journal Page 31 Component Societies and Affiliated Organizations Calendar of Upcoming Events
June 20-23, 2013 August 15-17, 2013 Annual Conference: Coming to Our Senses— Utah Osteopathic Medical Association 17th Annual An Osteopathic Approach to Cranial Nerve Disorders CME Conference: Healthcare for the Whole Family Course Director: Maria T. Gentile, DO CME: 24 Category 1-A AOA credits anticipated Associate Director: Dennis A. Burke, DO The DoubleTree Suites, Salt Lake City, UT Marriott Hotel, La Jolla, CA Phone: (801) 860-3812 CME: 20.75 Category 1-A AOA credits anticipated E-mail: [email protected] Phone: (317) 581-0411 Fax: (317) 580-9299 Web site: http://utahosteopathicmedicalassociation.org/ E-mail: [email protected] Web site: www.cranialacademy.org August 30-September 1, 2013 Osteopathic Physicians & Surgeons of California June 21-25, 2013 24th Annual Fall Conference Muscle Energy: Part I CME: 22 Category 1-A AOA credits anticipated Course Chairperson: Lisa A. DeStefano, DO InterContinental The Clement Monterey, Monterey, CA Restore Motion, Rockville, MD Phone: (916) 822-5246 Fax: (916) 822-5247 CME: 34 Category 1-A AOA credits anticipated E-mail: [email protected] Phone: (517) 353-9714 Fax: (517) 432-9873 Web site: http://www.opsc.org E-mail: [email protected] Web site: www.com.msu.edu/cme/courses.html September 20-22, 2013 The Next Step: Advancing Your Skills in August 1-4, 2013 Osteopathy in the Cranial Field Louisiana Osteopathic Medical Association Course Director: Paul E. Dart, MD Annual Convention: Focus on Primary Care Associate Director: Eric J. Dolgin, DO CME: 25-26 Category 1-A AOA credits anticipated DoubleTree Hotel, Portland, OR The Royal Sonesta Hotel, New Orleans, LA CME: 22 Category 1-A AOA credits anticipated Phone: (318) 385-7943 Fax: (318) 385-7934 Phone: (317) 581-0411 Fax: (317) 580-9299 E-mail: [email protected] E-mail: [email protected] Web site: www.loma-net.org Web site: www.cranialacademy.org
August 8-11, 2013 September 20-22, 2013 Colorado Society of Osteopathic Medicine Introduction to Osteopathic Medicine and Annual Meeting and Summertime CME Evaluation & Treatment: Thorax and Rib Cage CME: 25 Category 1-A AOA credits anticipated UNECOM, Biddeford, ME Beaver Run Resort & Conference Center, Breckenridge, CO CME: 20 Category 1-A AOA credits anticipated Phone: (303) 322-1752 Fax: (303) 322-1956 Phone: (207) 602-2589 E-mail: [email protected] E-mail: [email protected] Web site: www.une.edu/com/cme/manualmedicine.cfm Web site: http://www.coloradodo.org/ October 4-7, 2013 August 9-11, 2013 Exercise Prescription as a Complement to Manual Medicine Oklahoma Osteopathic Association Summer CME Seminar Course Chairperson: Mark Bookhout, MS, PT CME: 17 Category 1-A AOA credits anticipated MSUCOM, East Lansing, MI Sheraton Hotel at the Reed Conference Center CME: 26.5 Category 1-A AOA credits anticipated Midwest City, OK Phone: (517) 353-9714 Fax: (517) 432-9873 Phone: (405) 528-8625 Fax: (405) 528-6102 E-mail: [email protected] E-mail: [email protected] Web site: www.com.msu.edu/cme/courses.html Web site: http://www.okosteo.org
Page 32 The AAO Journal Volume 23, Issue 2, June 2013